1. Provider Barriers to Delivery of Quality Transgender Healthcare
Suthiratana Bhudvanbhen-Jung
DePaul University School of Nursing
Research Advisor: Veronica Drantz, PhD
Background
Transgender encompasses anyone who does not identify with the gender they were assigned at birth. Trans individuals may undergo hormone treatment, sex reassignment surgery, both interventions or neither. Due to the previous DSM-IV Gender Identity Disorder diagnosis, transgender was considered a pathology. Transgender individuals were often denied services that were related to transition or diagnoses centered gender identity as the primary cause. The 2013 DSM-V switch to Gender Dysphoria depathologized the transgender identity. Now, transgender care is covered by insurance and considered part of expected patient care. This research study focuses on provider reported barriers to trans healthcare over patient reported, though some patient reports were used in conjunction with provider perspective.
Discussion
The literature review reveals a need for providers and nurses to receive more cultural competency and focused healthcare training regarding the transgender population. Double the amount of people from 2013 to 2016 identify as transgender (Flores, Herman, Gates, & Brown, 2016), suggesting an emergent need for competent and informed healthcare staff prepared to deliver quality transgender healthcare. Transgender healthcare curricula and professional development for providers should become standard in order to bridge the knowledge gap.
Findings
Review of selected literature revealed three common themes pertaining to provider barriers regarding delivery of transgender healthcare.
Provider Bias
Transgender individuals experienced discrimination while seeking healthcare, transition related or standard.
Mental health diagnoses often centered the trans identity as the root cause rather than its own separate issue (Mizock, Fleming, 2011, p. 211).
Lack of medical staff consensus concerning treatment of transgender patients lead to use of the wrong pronouns and names, despite patient and other provider teams counseling otherwise.
Trans individuals were sometimes forced to live as their previously assigned gender while receiving medical care, causing some to avoid seeking care in their hometowns (Cartwright, Hughes, Leinert, 2012, 542).
Insurance providers denied transgender patients care, standard or transitional, based on their transgender status (Hanssmann, Morrison, Russian, Shiu-Thorton & Bowen, 2010, p. 241).
Lack of Training and Exposure
Providers admit to a knowledge gap regarding transgender patients that includes lack of training, lack of exposure to the population, and lack of knowledge of resources (Vance, Halper-Fisher, & Rosenthal, 2014, p. 252).
Fewer than 6 hours of classroom curricula and even fewer hours of clinical residency were spent on LGBTQ content (Obedin-Maliver, et.al., 2011).
Medical school location and existence of LGBTQ identifying staff members were significant influences concerning student exposure to LGBTQ patients and content (Moll, et. al., 2014, p. 608).
Cultural Competency
Providers failed to address gender identity. Simple reasons included time constraints, adolescent parent was present, or forgetting to ask. Other reasons included assumption of heterosexuality, inability to understand transgender identity, assumption that the patient would address gender, or disregard for gender identity relevancy to the visit (Kitts, 2010).
Diversity within the transgender community prevents providers from formulating a single method of working with transgender patients, complicating provider attempts to streamline transgender approaches to care.
Community based organizations attempt to bridge the knowledge gap with professional development programs showed that both single and continuous professional development helped providers improve their understanding of transgender healthcare obstacles and needs (Hanssmann, Morrison, Russian, Shiu-Thorton, & Bowen, 2010) (Porter & Krinsky, 2014).
Nursing Implications
Nurses need to be included in curricula development and cultural competency training because they spend the most time with patients.
Nursing assessments help shape provider diagnoses and plan of care, meaning they must be knowledgeable about trans healthcare in order to be accurate with their reports.
Nurse-patient interactions influence patient perception of their quality of healthcare. Culturally competent nurses would help trans patients have more positive healthcare experiences.
Purpose
The objective of this integrative literature review is to determine the main obstacles for providers when delivering standard or transitional healthcare for transgender individuals and determine the best ways to dismantle these obstacles constructively and ethically.
Methods
Research Design
The literature review is based on Whittlemore and Knafl’s (2005) methodology. The integrative literature review design allows for more studies to be considered for relevance. Other literature reviews, qualitative interviews, and data driven studies were reviewed to encompass provider barriers regarding delivery of transgender healthcare.
Search Methods
Research was conducted using CINAHL, ProQuest, and PubMed. For articles that did not meet search criteria, references were used to find other, more pertinent articles. Key words include: provider, barrier, transgender health.
Data Analysis and Synthesis
Articles were considered highly relevant if the study focused on provider perspective and if the study accomplished its goal or made significant findings. Sources were rated with either a 1 or a 2, depending on the rigor and relevancy of the study. Once the most relevant studies were isolated, they were reviewed for common themes and sorted accordingly. Some articles belonged in more than one category, which was indicated in the primary source matrix (Whittemore & Knafl, 2005).
Conclusion
Competency in transgender care can be considered an aspect of cultural competency that can enhance healthcare interactions between patients and providers. There is a psychosocial aspect as well as particular medical needs unique to this patient population. Along with community groups, medical groups and hospitals should begin their own focused education efforts to bridge the knowledge gap to work in synch with the community based groups who already offer cultural competency training.
References
Cartwright, C., Hughes, M., & Lienert, T. (2012). End-of-life care for gay, lesbian, bisexual and transgender people. Culture, Health & Sexuality, 14(5),
Hanssmann, C., Morrison, D., Russian, E., Shiu-Thornton, S., & Bowen, D. (2010). A community-based program evaluation of community competency trainings. JANAC: Journal Of The Association Of Nurses In AIDS Care, 21(3), doi: /j.jana
Kitts, R.L. (2010) Barriers to Optimal Care between Physicians and Lesbian, Gay, Bisexual, Transgender, and Questioning Adolescent Patients, Journal of Homosexuality, 57:6, , DOI: /
Mizock, L., & Fleming, M. Z. (2011). Transgender and gender variant populations with mental illness: implications for clinical care. Professional Psychology: Research & Practice, 42(2), doi: /a
Moll, J., Krieger, P., Moreno-Walton, L., Lee, B., Slaven, E., James, T., & ... Heron, S. L. (2014). The Prevalence of Lesbian, Gay, Bisexual, and Transgender Health Education and Training in Emergency Medicine Residency Programs: What Do We Know? La Prevalencia de la Educación Sanitaria. Formación sobre Lesbianas, Gays, Bisexuales y.. Academic Emergency Medicine, 21(5), doi: /acem.12368
Obedin-Maliver, J., Goldsmith, E., Stewart, L., White, W., Tran, E., Brenman, S., & ... Lunn, M. (2011). Lesbian, gay, bisexual, and transgender-related content in undergraduate medical education. JAMA: Journal Of The American Medical Association, 306(9), doi: /jama
Porter KE, Krinsky L.(2014) Do LGBT aging trainings effectuate positive change in mainstream elder service providers? J Homosex. 61(1): doi: / PubMed PMID:
Vance, S. R., Jr., Halpern-Felsher, B. L., & Rosenthal, S. M. (2015). Health Care Providers' Comfort With and Barriers to Care of Transgender Youth. Journal Of Adolescent Health, 56(2), doi: /j.jadohealth
Whittemore, R., & Knafl, K. (2005). The integrative review: updated methodology. Journal Of Advanced Nursing, 52(5),
Methodist Hospital Foundation, 2009